Provider Demographics
NPI:1942437140
Name:MANCELL, JERED MARC (DO)
Entity Type:Individual
Prefix:DR
First Name:JERED
Middle Name:MARC
Last Name:MANCELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 9TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-1548
Mailing Address - Country:US
Mailing Address - Phone:605-882-7000
Mailing Address - Fax:
Practice Address - Street 1:401 9TH AVE NW
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-1548
Practice Address - Country:US
Practice Address - Phone:605-882-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018298207YS0123X
SD9230207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery